| NPI | 1902257553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MN 9148) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 5012932) |
| 363LF0000X Nurse Practitioner, Family (Licence: GA RN216596) | |
| Enumeration Date | 2016-06-24 |
| Last Update Date | 2022-05-02 |